Provider Demographics
NPI:1861470395
Name:MIDDLEBROOKS, PETER K (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:K
Last Name:MIDDLEBROOKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CEDAR ST SE SUITE 6600
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-724-4300
Mailing Address - Fax:505-724-4384
Practice Address - Street 1:201 CEDAR ST SE SUITE 6600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1173508225100000X
NM26082251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB8237Medicaid
TX8T7931OtherBLUE CROSS BLUE SHIELD
TX8T7931OtherBLUE CROSS BLUE SHIELD